2017’s State Uninsured Rates

Sep 15, 2017 | John S Kiernan, Senior Writer & Editor

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Having health insurance is vital to the well-being of your family and your wallet. It not only ensures that you have access to the care you need, but it also can significantly reduce your out-of-pocket medical expenses, the leading cause of personal bankruptcy in the U.S.

Much to the credit of the Affordable Care Act — dubbed “Obamacare” — the uninsured rate for all Americans dipped to a historic low of 8.6 percent in the first three months of 2016, according to the National Health Interview Survey conducted by the Centers for Disease Control and Prevention. But the uninsured rate is back on the rise in 2017 and continues to vary dramatically across states.

With the fate of the ACA still undetermined, WalletHub’s analysts measured the post-Obamacare uninsured rates in each of the 50 states. For an even broader perspective of those rates, we broke the national figures down to categories such as race and income level. In addition, we conducted the same analysis at the city level. Read on for our findings, expert insight from a panel of experts and a full description of our methodology.

Uninsured Rates over Time

Medicaid States vs. Non-Medicaid States

Red vs. Blue States

Ask the Experts

For insight on the future of the ACA, we asked a panel of experts to share their thoughts on the following key questions:

To what extent will President Donald Trump’s decision to reduce spending on advertising and other efforts to inform people about deadlines to sign up for ACA coverage have an effect on enrollment in fall 2017?

Given Congress’ inability to pass health-care reform in summer 2017, what are the tradeoffs between “fixing” Obamacare versus starting from scratch with a new system?

What do you think is the most common misconception people have about Obamacare?

Robert I. Field

Professor of Law in the Thomas R. Kline School of Law, Professor of Health Management & Policy in the Dornsife School of Public Health, and Director of JD-Master of Public Health Program at Drexel University

To what extent will Trump’s decision to reduce spending on advertising and other efforts to inform people about deadlines to sign up for ACA coverage have an effect on enrollment this fall?

The cuts to ACA outreach efforts are likely to have a major effect on enrollments this fall. How can people sign up for something if they don’t know it’s there? The effect will be magnified by the shortened enrollment period this year. If people are not warned about the new deadline, the window for signing up may close before they realize it had opened.

Given Congress’ inability to pass health care reform this past summer, what are the tradeoffs between “fixing” Obamacare versus starting from scratch with a new system?

None of the proposals that Congress considered this past summer would have created a new system. They simply chipped away at Obamacare. To varying degrees, they would have shrunken enrollment on the exchanges and undermined Medicaid, while taking coverage away from about 20 million people. In fact, no serious alternative to the Obamacare approach has ever been proposed, aside from a single-payer system, which remains a political long-shot. A few simple “fixes” could substantially strengthen Obamacare, and they would have been enacted several years ago had the law not become such a partisan battlefield.

What do you think is the most common misconception people have about Obamacare?

People tend to think of Obamacare as primarily a plan to help poor people buy health insurance. It does that, but it also helps everyone by guaranteeing access to coverage without regard to health status. Almost anyone could find themselves in need of that protection at some time.

Michael J. McCue

R. Timothy Stack Professor of Health Administration in the School of Allied Health Professions at Virginia Commonwealth University

To what extent will Trump’s decision to reduce spending on advertising and other efforts to inform people about deadlines to sign up for ACA coverage have an effect on enrollment this fall?

Reducing time frame/advertising of the enrollment period will certainly impact the number of members signing up for ACA coverage, especially younger, healthier members. In order for the individual market to limit the increase in its premiums, the market requires a large enough risk pool that includes both young and healthy members to offset older, unhealthy members.

Given Congress’ inability to pass health care reform this past summer, what are the tradeoffs between “fixing” Obamacare versus starting from scratch with a new system?

Since the majority of the larger, publicly-traded health insurers have exited the market, the individual market now depends upon smaller regional and Blue Cross carriers to cover members within the individual market. These smaller regional insurers, which include many health plans sponsored by health care system or startup carriers, such as Oscar Health Insurance, have already invested capital resources and personal to comply with the ACA market. The thin or no margins that these insurers may have generated limits their financial ability to revamp their actuarial systems to price their health plans, as well as retrain the support staff to learn a new health system.

The remaining ACA carriers have four years of experience operating administratively and managing care within the ACA market. For example, one carrier, Centene, has performed well enough to expand its ACA coverage within existing markets, as well as new markets. Centene’s entry into this market is driven by applying its expertise in claims and medical management of the low-income, sicker Medicaid population to the ACA market, which included similar members.

What do you think is the most common misconception people have about Obamacare?

The primary misconception is that the everyday consumer assumes that ACA or Obamacare affects everyone that is insured, including individuals insured by their employers. There are certain ACA regulations that impact the group markets and companies that are self-insured (e.g., all employers must offer health insurance, preventive medical services require no co-payment); however, the majority of the ACA regulations only impact the individual market. The individual market membership only accounts for about 7 percent of the commercial insurance market. Therefore, the projected substantial premium increases -- 28 to 40 percent that are reported in the press only relate to the individual market, especially with regard to the removal of the cost-sharing subsidies and not group markets. In contrast, employee covers by the employer, group market insurance, is expected to increase by only five percent.

Wendy Max

Director of the Institute for Health & Aging and Professor of Health Economics at the University of California San Francisco School of Nursing

To what extent will Trump’s decision to reduce spending on advertising and other efforts to inform people about deadlines to sign up for ACA coverage have an effect on enrollment this fall?

The people who most need health care insurance are those least likely to know how to get it. Thus, it is critical to make it as easy as possible for people to know what they need to do to sign up. Cutting the advertising and outreach efforts is the beginning of “death by a thousand cuts.” Fewer will sign up and this will be misinterpreted as a lack of interest or need, further exacerbating the self-fulfilling prophecy of the current administration of implosion of the ACA. Spending less here is a terrible idea, likely to lead to disastrous results for the ACA, but more importantly, for many Americans who need health care.

Given Congress’ inability to pass health care reform this past summer, what are the tradeoffs between “fixing” Obamacare versus starting from scratch with a new system?

I believe that one has to start somewhere to achieve health care reform, and that the ACA was a wonderful starting point. Was it a perfect program? No, of course not. There is much that can be improved. We have learned a lot since it was implemented. The same happened 50 years ago, when Medicare was implemented. The program has been improved and refined many times and this will continue into the future. But the result was that millions of seniors now have health care at a time in their lives when this is critical.

If starting over is needed so that the Republicans can take care for a new health insurance program, then so be it. What is more important than who gets the credit is that some form of health care reform continues. To me it seems a waste to scrap a program that had so much to recommend it and has so many popular provisions (ask any parent of a 24-year-old, or anyone with a pre-existing condition). But again, the uncertainty the administration has already created around health care reform has already by itself caused major problems, such as insurers pulling out of some markets. It is imperative that the president and Congress stop playing political football with people’s lives.

What do you think is the most common misconception people have about Obamacare?

People blame insurance rate increases on Obamacare. While this is true to some extent, the point is that when you add millions of Americans to the insured ranks, we have to pay for this somehow. And of course, those who were unable to get insurance before were in many cases the sickest, those who weren’t working due to illness and thus had no access to employer-provided insurance, or who couldn’t afford individual policies due to preexisting conditions. It is not fair to say that the program drove costs up -- of course it did, but shouldn’t we be willing to pay something to make sure everyone has access to good health care?

Michael K. Gusmano

Associate Professor of Health Policy and Member of the Institute for Health, Health Care and Aging Research at Rutgers University School of Public Health

To what extent will Trump’s decision to reduce spending on advertising and other efforts to inform people about deadlines to sign up for ACA coverage have an effect on enrollment this fall?

The analysis of the Trump administration's decision to pull advertisements during the last open enrollment period suggests that it had a significant impact on enrollment. It is possible that, with more lead time, there may be a number of advocacy groups (and some state governments) that step in and fill some of the gap left by federal advertising, but I suspect that this will still lead to lower enrollment than we would see with the ads. Many people, particularly younger, healthier people, wait until the last minute and are less likely to enroll in the marketplaces if they are not reminded in a timely way. If you couple this decision with the decision of the IRS under President Trump, to accept "silent" returns in which people do not indicate whether they have complied with the individual mandate, it is a recipe for limiting enrollment in ways that could undermine the risk pools.

Given Congress’ inability to pass health care reform this past summer, what are the tradeoffs between “fixing” Obamacare versus starting from scratch with a new system?

If "starting from scratch" means going back to the pre-ACA system, in which health insurance companies would base premiums on health status, deny people with pre-existing conditions the ability to purchase insurance, and rescind policies from people who made minor errors on their applications -- and a system in which about 20 million more Americans were uninsured -- then there is now question that attempting to fix the ACA is a preferable alternative.

The idea that we could go back and create a law that is more comprehensive and does a better job of addressing cost pressures does not seem politically realistic. I think it is reasonable to suggest that the Obama administration and congressional leaders got as much as they could. They received no Republican support and had to negotiate with Democrats on the left and right-wing fringes of the party, who would not have supported a "single payer" solution (the favorite of those on the left) or even the so-called "public option," which would have provided a lower-cost, more efficient public insurance option for people purchasing insurance through the exchanges. If they could not get the votes to go beyond the ACA in 2009-10, it certainly would not be possible now.

There is no question that, despite all of its accomplishments, the ACA has problems. The fact that the Supreme Court ruled that the federal government could not threaten to remove all Medicaid matching funds from states that chose not to expand the Medicaid program meant that there are large disparities in insurance coverage among the states. The penalty (tax) associated with failing to purchase health insurance is too low, and many people still choose not to comply with the mandate. For many others, the subsidies are inadequate, and it is difficult for them to afford decent health insurance. Perhaps most importantly, the ACA never included serious cost control provisions, and insurance companies responded to risk pool problems by creating so-called "narrow" networks that limited the care available to many people with insurance. These are all fixable problems, but none of those solutions are going to be enacted unless the balance of power changes in Washington, DC.

Even without Congressional action, it seems more likely that, through waivers, executive orders, and decisions of the sort you mention above (failing to fund outreach), the Trump administration will attempt to undermine the ACA as a way of claiming that the program is "imploding."

What do you think is the most common misconception people have about Obamacare?

I think opponents have successfully blamed many problems with the health insurance system on the law. In particular, opponents have attributed increases in insurance premiums and reductions in health insurance networks to the ACA. In reality, insurance premiums and the scope of networks were moving in this direction before the ACA. Because the law failed to address the cost of health care in the U.S., it did not solve these problems, but it did not create them. If anything, by expanding the pool of people with insurance coverage and offering significant subsidies for people with incomes between 135-400% of the federal poverty level, the ACA made insurance far more affordable for millions of people and, even with its limitations, the situation would be far worse without the law.

Leighton Ku

Professor and Director of the Center for Health Policy Research in the Milken Institute School of Public Health at George Washington University

To what extent will Trump’s decision to reduce spending on advertising and other efforts to inform people about deadlines to sign up for ACA coverage have an effect on enrollment this fall?

It is too early to be certain of the effects of slashing funding for outreach, but it surely cannot be positive. A new study by the Commonwealth Fund finds that about 40% of uninsured adults were not aware of the exchanges, and that those who received more active assistance from "navigators" were more likely to enroll in the exchanges.

These problems may be compounded by the fact that the Administration shortened the open enrollment period during which people can sign up. And the chaos about the Congressional debate and questions about other issues may confuse consumers, and make them less certain that the exchanges will provide good insurance.

On the other hand, the exchanges have been around for a few years now and the websites (HealthCare.gov) are more functional, so it is easier to know about the program and how to join.

Given Congress’ inability to pass health care reform this past summer, what are the tradeoffs between “fixing” Obamacare versus starting from scratch with a new system?

At this point, fixing is the only realistic option and there is bipartisan support for incremental changes to stabilize the insurance market. The Senate has been holding hearings on this topic, and there seems to be broad support. It would be impossible for Congress to agree on a start-from-scratch approach right now.

What do you think is the most common misconception people have about Obamacare?

The most common myth -- perpetuated by President Trump -- is that Obamacare is collapsing and that prices are soaring. At this point, every county in the country has at least one insurer participating in the exchange, offering a number of plan choices. While premiums are rising, health insurance prices always rise, and most exchange participants get help through federal tax credits. As premiums rise, the tax credits also rise to keep prices lower for consumers. About 75-80% of those enrolling get tax assistance to keep their prices low. Much of the new price increases (that will affect rates in 2018) have been created by the uncertainty caused by the President's policies.

John W. Huppertz

Associate Professor and Chair of the MBA Healthcare Management Program at Clarkson University

To what extent will Trump’s decision to reduce spending on advertising and other efforts to inform people about deadlines to sign up for ACA coverage have an effect on enrollment this fall?

It's very difficult to assess the impact of advertising on any product or service, but there is abundant evidence that advertising builds awareness, which serves as the foundation for consumers' purchase decisions. If people are not aware of your product or brand, how are they going to buy it?

The Trump administration has proposed a 90% cut in advertising for open enrollment, the period during which people decide on a health plan for the upcoming year. The worry is that cutting advertising so drastically will reduce the number of younger, healthier people signing up for Obamacare on the exchanges. Health insurance is not a product that people want to buy. They'd rather not think about it unless they need to, which means that regardless of the amount spent on advertising, older and sicker people are most likely to sign up, while younger people won't pay attention unless reminded about it. Furthermore, with all the talk about repealing and replacing Obamacare, some people may assume it's gone, unless they see advertising or other communications to let them know differently. So, I think these reductions will have a significantly negative effect on enrollment, especially among the people most needed in the risk pool.

What do you think is the most common misconception people have about Obamacare?

That it's bad. Everyone agrees that Obamacare is far from perfect and needs fixing, but it's worked for millions of people, some of whom don't even know they are getting their health insurance through the Affordable Care Act. Opponents have promoted the idea that Obamacare somehow harms people, or that patients are suffering because of it, and that misconception has stuck.

John Billimek

Assistant Professor In-Residence in the Health Policy Research Institute at the University of California, Irvine School of Medicine

To what extent will Trump’s decision to reduce spending on advertising and other efforts to inform people about deadlines to sign up for ACA coverage have an effect on enrollment this fall?

I assume it will have a negative effect on new enrollments during the open enrollment period, but this will definitely vary by community. In many communities, there are strong local efforts to encourage people to enroll in health insurance, which could mitigate the loss in advertising dollars. Also, at least in California, and likely in other states as well, most people who were already enrolled in coverage for 2017 would be automatically renewed for 2018, even if they don’t submit a renewal application. So most of the loss in enrollment would likely be in new enrollees.

Given Congress’ inability to pass health care reform this past summer, what are the tradeoffs between “fixing” Obamacare versus starting from scratch with a new system?

Starting from scratch would be extraordinarily disruptive for insurers, health care organizations, and business owners in the economy at large. This is why Repeal and Replace was so unpopular nationally, even among many opponents of Obamacare. Republicans and Democrats, however, almost universally agree that the ACA can be improved, so there is some fixing that should be done to move toward cost containment and insure adequate health coverage throughout the country. This is best done incrementally.

What do you think is the most common misconception people have about Obamacare?

I think the most common misconception about the ACA is the same as what we see for health insurance in general.

Many people think of health insurance like a subscription service like Netflix, where you pay a monthly fee to get unlimited access to health care services. In this scenario, you would only sign up for health insurance during a year when you plan to use services that cost more than the price of your premiums. When you hold this misconception that health insurance is meant to be subscription service (that people will “game” to get out of it more than they put into it), then I understand why some people don’t think it should be required for all people to have it.

But the reality is that insurance is not meant to be a subscription service, but is intended to spread the risk for financial hardships related to health among many people. You buy it because you don’t know whether (or when) you will need it. Health insurance is like car insurance or homeowner’s insurance, where everyone pays something every year so you know you will be covered if something bad happens, with the one important difference that losses related to health often unfold over many years. We know that pretty much everyone will have significant health expenses in their life, but we don’t know how much they will be -- or more importantly, whether they will come when I am 45 or 95. Or how long they will last -- a sudden death by car accident versus years of expensive treatment for cancer or Parkinson’s disease.

In a lifetime, some people may end up paying more in insurance premiums than they end up using in services, and some will use services that would have cost far more than their premiums. But predicting which category you’ll fall into is very hard to do. And we have much less control of the amount and timing of our medical needs than we wish we did. So, of course, health insurance provides opportunities for preventive care and early detection of disease that may prolong healthy life. But its biggest impact is to take out much of the uncertainty all people face (but few realize) in the total lifetime costs of health care. In that way, the ACA provides freedom for families and business owners to make financial decisions with much less worry about unpredictable, and often uncontrollable, future medical expenses.

James A. McCubbin

Professor of Psychology and Public Health Sciences in the College of Behavioral, Social and Health Sciences at Clemson University

To what extent will Trump’s decision to reduce spending on advertising and other efforts to inform people about deadlines to sign up for ACA coverage have an effect on enrollment this fall?

I believe the cutback on the ACA spending on advertising and informational support personnel will effectively decrease enrollment, and further sabotage the ACA’s mission to reduce the ranks of uninsured in the U.S. Uninsured persons contribute to the high cost of U.S. health care in many ways, including use of expensive emergency room services for non-emergencies, increases in the severity of diseases like breast cancer, because of reduced access to proactive, preventative screenings for early detection, and contribution to our already unacceptably high infant mortality rate, due to lack of access to prenatal care. The cutbacks are analogous to failing to water a plant. Without water, a plant will die. Without advertising and support for potential enrollees, the ACA’s demise will become a self-fulfilling prophecy; a failure both predicted and engineered by the same people, to the disadvantage of all citizens of the U.S.

Jack Hoadley

Research Professor in the Health Policy Institute at Georgetown University

To what extent will Trump’s decision to reduce spending on advertising and other efforts to inform people about deadlines to sign up for ACA coverage have an effect on enrollment this fall?

These decisions by Trump could have a substantial dampening effect on enrollment. When advertising was cut off early by Trump this past January, we saw a clear drop-off in enrollment; the same result is likely this fall. One large concern is that people who are healthier may fail to enroll without the encouragement provided by advertising. If this happens, it will lead to adverse selection in the risk pool, and ultimately to higher costs and higher premiums. But I am also concerned that the loss of the navigator resources resulting from large cuts in funding for these programs will leave many people without the help they need to get themselves signed up. Trump's decisions will likely mean higher costs per person, but fewer people enrolled -- a double dose of bad outcomes.

Given Congress’ inability to pass health care reform this past summer, what are the tradeoffs between “fixing” Obamacare versus starting from scratch with a new system?

The legislation that was proposed and rejected during the summer would have taken significant steps backward and would have resulted in less coverage and higher costs for those who remained covered. We now have the opportunity to pass fixes to improve the system and give Obamacare a chance to work out its kinks. In the immediate term, this means guaranteeing funding for the cost sharing reductions; instituting reinsurance to give the system protection against unexpected costs; increasing rather than reducing funding for outreach and assistance to those who want to enroll; and making provisions for backup plans for any areas where all plans pull out, and potentially to increase competition in areas with only a single plan.

We also need to see a reversal by the states that failed to take up Medicaid expansion, so that their residents can take advantage of this important program. In the longer term, we should be considering how to improve the generosity of the subsidies and how to scale back some of the deductibles and other cost sharing that make it difficult for those with coverage to use their benefits.

What do you think is the most common misconception people have about Obamacare?

The biggest misconception is the tendency to blame anything that goes wrong in health care on Obamacare. Rising costs and rising premiums are driven by many things, including high drug prices, use of unnecessary services, and increased consolidation in health care, to name just a few. These are broad trends that are not attributable to Obamacare. Obamacare has dramatically increased the number of people with health coverage, and we need to give it more time to work, while also making some critical fixes.

Harrison Alter

Associate Chair for Research in the Department of Emergency Medicine at Highland Hospital – Alameda Health System

To what extent will Trump’s decision to reduce spending on advertising and other efforts to inform people about deadlines to sign up for ACA coverage have an effect on enrollment this fall?

I work in the ER at a public hospital in Alameda County, California. Our county had among the highest rates of ACA uptake in the country, primarily among residents eligible for Medicaid. I don't know what this has meant to my hospital's bottom line, but I do know that in the year before ACA implementation, 52% of people coming for care to our ER lacked health insurance, or were covered by a county plan for medically indigent adults. A year after rollout of the ACA, that figure was down to 18%.

Given Congress’ inability to pass health care reform this past summer, what are the tradeoffs between “fixing” Obamacare versus starting from scratch with a new system?

I recently reread Richard Nixon's description of his Comprehensive Health Insurance Program, a universal coverage bill that he tried to advance in Congress in 1971. The medical-industrial complex assured that it would end in collapse, and that was before introducing anything like the partisan polarization we have today. It was an ambitious plan, and it would have entirely transformed U.S. medical care. I just can't imagine anyone having moxie to try it today. The truth is that Obamacare saves lives -- and not just through coverage -- so we should try to salvage it. The ACA has all kinds of other provisions -- for example encouraging, if only modestly, the incorporation of social context into medical care -- that contribute to its heroism.

What do you think is the most common misconception people have about Obamacare?

The most tragic misconception is that it is not just a nickname for the ACA. But the strategic mischaracterizations and outright lies about the ACA are so numerous and so widespread, as to defy an accounting. It is such a delicate balancing act, though, that the idea that you can keep parts you like while jettisoning, for example, the individual mandate -- that is just a fantasy.

Gilbert Gimm

Associate Professor in the Department of Health Administration & Policy at George Mason University

To what extent will Trump’s decision to reduce spending on advertising and other efforts to inform people about deadlines to sign up for ACA coverage have an effect on enrollment this fall?

I think President Trump’s decision to reduce funding to support advertising and other ACA outreach efforts is likely to diminish ACA enrollment in some local markets, where public awareness of ACA eligibility is limited. However, this effect is likely to be modest.

Given Congress’ inability to pass health care reform this past summer, what are the tradeoffs between “fixing” Obamacare versus starting from scratch with a new system?

In my opinion, repealing Obamacare and starting from scratch would be very disruptive to markets, providers, and the public. Because Obamacare has become deeply embedded in the U.S. health care system after years of implementation, it would be better to try to “fix” Obamacare. However, since Congress was not able to pass any health care reform in 2017 (due to Senator McCain’s influential “no” vote), I would argue that health care reform should wait until other legislative priorities (i.e., debt ceiling, tax reform) are addressed first.

What do you think is the most common misconception people have about Obamacare?

I think one of the most common misconceptions about Obamacare is that it is solely responsible for U.S. health care spending growth. Instead, I would argue that new medical innovations and technology play a greater role and contributing factor in U.S. health care spending growth.

George P. Sillup

Chair and Associate Professor of Pharmaceutical and Healthcare Marketing at Saint Joseph's University

To what extent will Trump’s decision to reduce spending on advertising and other efforts to inform people about deadlines to sign up for ACA coverage have an effect on enrollment this fall?

I believe this will make it more difficult to enroll, particularly for the pool of potential participants, who don't have or have limited access to computers.

While there are some effective electronic guides, such as the HealthCare.gov blog, many of the candidates for this coverage either don't use computers or have difficulty doing so.

Given Congress’ inability to pass health care reform this past summer, what are the trade-offs between “fixing” Obamacare versus starting from scratch with a new system?

Fixing the ACA is our most viable approach, because there is no alternative. You don't burn the bridge until you build a new one and, despite rhetoric, President Trump and those Republicans aligned with him on this issue really don't have a substantive option to health care insurance, especially for those who need it most. Trump Care(less) at this time is going back to market-based health care insurance options. God help the uninsured patient with a precondition.

Alternatively, fixing Obamacare isn't that easy. Three areas that can yield potential are:

Address the high cost of buying insurance through the exchanges by having the federal government intervene, and invest more so it costs people less, or subsidize insurers so they provide coverage at a reasonable price. Of the two, I'm more comfortable with former.

Have a larger non-enrollment penalty; a $695 penalty is not a large enough deterrent to motivate a healthy, young person to buy insurance that will cost him/her considerably more.

Constraint the impact of special interest groups, e.g., AMA, PhRMA. While the U.S. is not ready for a single-payer system, perhaps an adjustment for older Americans could make a discernible difference. An example is government-run health care insurers for those 55 and older, taken form the vestiges of Sanders and Hillary Clinton.

What do you think is the most common misconception people have about Obamacare?

Many Americans are confused about its cost and its required enrollment. For cost, it ranges from those who aren't aware that there is a charge connected to it, to those who get "sticker shock" once they see the cost. For the requirement to have health care coverage, many are in denial or willing to take the risk of not having it (as mentioned earlier). Using mandatory auto insurance is a comparison, there are still about 14% of drivers who do not carry auto insurance in the 47 states that require it for the last 60 years.

Diane M. Howard

Associate Professor in the Department of Health Systems Management and Director of Student Development at Rush University Medical Center

To what extent will Trump’s decision to reduce spending on advertising and other efforts to inform people about deadlines to sign up for ACA coverage have an effect on enrollment this fall?

The Associated Press reported that under the Trump Administration, proposed 2017 funding for marketing and recruitment would be reduced from $100 million to $10 million, and navigator funding would be reduced from $62 million to $36 million in 2018. Funding for enrollment impacts the education and information flowing to the population, and provides the resources to bring previously under- and uninsured citizens into the insurance system.

The uncertainty that has been introduced into the insurance market presents challenges for insurers, providers, and citizens looking to get coverage. The climate of uncertainty has forced insurers to exit markets, put providers -- be they hospitals, physicians, or ancillary providers -- into a defensive mode to limit services, and reduced or eliminated insurance choices for the population.

Regardless of one’s political views, the ACA restructured health care to allow those without insurance to purchase coverage, thereby giving them access to the provider community that may have been reluctant to accept the financial risk of treating patients without coverage.

Given Congress’ inability to pass health care reform this past summer, what are the tradeoffs between “fixing” Obamacare versus starting from scratch with a new system?

The inability this past summer to repeal and replace the Affordable Care Act was an education for members of Congress that demonized a piece of legislation that did good for so many people. The complexity and profound restructuring that the bill initiated in the insurance and provider communities was not understood. The public reaction around the country when legislators went home to their districts was a wake-up call and an education to those who used the ACA to score political points.

While the ACA is not perfect, there were over 100 key informants from the insurance and provider communities that help craft the legislation and 7 years of health care restructuring to address cost, quality, and access issues. A tremendous effort was put into moving health care from being a commodity to being a public good while keeping it in the private marketplace. Now, the hard part will be to bring opposing sides together to examine the original intent of the legislation and find common ground to modify what is not working.

What do you think is the most common misconception people have about Obamacare?

The common misconceptions are that the U.S. health care system is the best in the world, that the Affordable Care Act comes between a physician and the patient, that patient outcomes are optimal, that there is no need for innovation in health care, that 1 in 6 dollars of the economy spent on health care is spent wisely, that altering the battleship that is health care is easy, and that there is no need for change.

David Anderson

Research Associate in the Robert J. Margolis, MD, Center for Health Policy at Duke University

To what extent will Trump’s decision to reduce spending on advertising and other efforts to inform people about deadlines to sign up for ACA coverage have an effect on enrollment this fall?

There is good evidence that advertising increases enrollment. Furthermore, we know that the individuals who are the last people to sign up and who need the most reminders to sign up are likely to be healthier and less expensive than average (as presented here and here). Individuals with significant and expensive health needs will disproportionally sign up for coverage, absent advertising. The health of the risk pools, and thus the level of long-run premiums is directly tied to the number of healthy people who sign up. Reducing advertising, restricting limited outreach to non-television broadcast channels, not paying for navigators and other efforts to minimize the visibility of the open enrollment period will depress enrollment.

I have not seen credible point estimates of expected enrollment. However, insurers in their rate filings have been expecting a sicker risk pool due to administrative actions that deter healthy individuals from signing up. Insurers have been increasing their premiums to partially account for a sicker risk pool. I would expect enrollment in states served by HealthCare.gov to decrease, while states that run their own exchanges and manage their own outreach should not see significant decreases in enrollment.

Given Congress’ inability to pass health care reform this past summer, what are the tradeoffs between “fixing” Obamacare versus starting from scratch with a new system?

There are a number of areas where Obamacare needs to be improved, modified and tweaked. The framework of the ACA is fairly flexible and conducive to changes in many ideological directions. Subsidies can be increased or decreased. Allowed out-of-pocket amounts can be increased or decreased. Minimum standards can be altered. Health Savings Accounts are already incorporated in some plan designs. The interaction of exchange policies with Medicaid, CHIP and employer sponsored plans can conceivably be modified. The fundamental skeleton has been built up over the past seven years and it is flexible enough to accommodate significant changes if there is a coalition in Congress that can assemble a package. Scrapping this skeleton and moving to a new system would be expensive, time-consuming and at risk of catastrophic failure.
The transition from the current state of the health care system to any desired future state is long and fraught. We saw the 3.5 years of transition time from the signing of the ACA to the first day of open enrollment in October, 2013 to not be enough. Almost no changes to the law of any sort will have meaningful impact on 2018 policies if the modification was to be signed into law today. Twenty-four to thirty months is the minimal needed transition time for major reforms of any sort.

What do you think is the most common misconception people have about Obamacare?

I think there are two significant misconceptions of the law that many people have. The first is that it is much more limited law than some believe. The ACA has led to a roughly 10% decline in the uninsured rate. It minimally touches the benefit and administration of benefits for people who receive their insurance through a work-based arrangement. It makes behind-the-scene changes to Medicare. The largest changes are in the individual market and Medicaid -- otherwise, it lightly touches most of the insurance market.

The second misconception is that the subsidized buyers of insurance on the Exchange are specially targeted for subsidies, instead of the realization that very few people in America pay the entire cost of their insurance by themselves. Everyone who has insurance through work receives a tax break, almost everyone who has Medicare is being subsidized by the general population. These subsidies are masked so most people don’t see the covert subsidy that they receive, while the ACA makes individual market subsidies explicit. But the overwhelming majority of Americans who are insured receive some type of subsidy, overt or covert.

Methodology

In order to measure the rates of uninsured by state, WalletHub’s analysts compared the overall insurance rates in the 50 states in 2016 using U.S. Census Bureau data. In addition to comparing overall insurance rates, we examined the state rates based on age, race and income.

An overall rank of No. 1 corresponds with the state with the lowest uninsured rate. When viewing our findings in the above tables, please note that the change in uninsured rate refers to the difference between the percentages of uninsured in 2016 and 2010. A small change in the absolute difference does not necessarily indicate a negative outcome, as the percentage of uninsured people pre-Obamacare may have already been low to start with.

Health Insurance Rate by Age Group

Health Insurance Rate for Children (Aged 0 to 17)

Health Insurance Rate for Adults (Aged 18 & Older)

Health Insurance Rate by Race/Ethnicity

Health Insurance Rate for Whites

Health Insurance Rate for Black or African Americans

Health Insurance Rate for Hispanic or Latino

Health Insurance Rate by Household Income

Health Insurance Rate for Lower-Income Households ($50,000 or less)

Health Insurance Rate for Higher-Income Households ($100,000 or more)

Sources: Data used to create this ranking were collected from the U.S. Census Bureau.

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